What is the preferred steroid for a Crohn's (Crohn's disease) flareup?

Preferred Steroids for Crohn's Disease Flareup

For a Crohn's disease flareup, oral budesonide 9 mg/day is the preferred first-line steroid for mild to moderate ileal and/or right colonic disease, while oral prednisone 40-60 mg/day is recommended for moderate to severe disease or when budesonide fails. 1

Steroid Selection Based on Disease Severity and Location

Mild to Moderate Disease

• Ileal and/or Right Colonic Disease:

  • First-line: Budesonide 9 mg/day orally 1
  • Evaluate response between 4-8 weeks 1
  • Benefits: Lower systemic side effects due to high first-pass metabolism in the liver 1, 2
  • Note: Slightly less effective than prednisolone but with fewer corticosteroid-associated side effects 2

• Colonic Disease (Limited to Colon):

  • Consider sulfasalazine 4-6 g/day for mild colonic disease 1
  • Evaluate response between 2-4 months 1

Moderate Disease (After Budesonide Failure)

• Prednisone 40-60 mg/day orally 1
• Evaluate response between 2-4 weeks 1

Moderate to Severe Disease

• Prednisone 40-60 mg/day orally 1
• Strong recommendation despite low-quality evidence 1
• Induces remission in 60-83% of patients versus 30-38% with placebo 1
• Evaluate response between 2-4 weeks 1

Severe Disease Requiring Hospitalization

• Intravenous methylprednisolone 40-60 mg/day 1
• Evaluate response within 1 week 1

Important Considerations

Efficacy and Monitoring

• Prednisone is more effective at reducing Crohn's Disease Activity Index scores compared to budesonide (279 to 136 vs. 275 to 175) 2
• Budesonide achieves remission in 53% vs. 66% with prednisolone (not statistically significant) 2
• Morning plasma cortisol concentrations are significantly less suppressed with budesonide compared to prednisolone 2

Duration and Tapering

• Steroids should only be used for induction of remission, not maintenance 1
• Strong recommendation against using steroids for maintenance of remission 1
• Too rapid reduction can be associated with early relapse 1
• Standard weaning strategy helps identify patients who relapse rapidly 1

Side Effects and Complications

• Corticosteroid-associated side effects are significantly less common with budesonide (29 patients) compared to prednisolone (48 patients) 2
• Serious complications with prednisolone can include intestinal perforation and abdominal-wall fistula 2
• Approximately 50% of patients who initially respond to corticosteroids develop dependency or relapse within 1 year 3
• Side effects can involve nearly every major body system including bone loss, metabolic complications, increased intraocular pressure, and potentially lethal infections 3

Steroid-Sparing Strategies

• Consider thiopurines for patients who:

  • Require two or more corticosteroid courses within a calendar year
  • Relapse as steroid dose is reduced below 15 mg
  • Relapse within 6 weeks of stopping steroids
  • Need postoperative prophylaxis for complex Crohn's disease 1

• Consider parenteral methotrexate for corticosteroid-dependent/resistant disease 1

Common Pitfalls to Avoid

1. Using steroids for maintenance therapy (ineffective and dangerous) 1
2. Failing to evaluate response within appropriate timeframes (2-4 weeks for prednisone, 4-8 weeks for budesonide) 1
3. Tapering steroids too rapidly, which can lead to early relapse 1
4. Not implementing steroid-sparing strategies for patients who become steroid-dependent 1
5. Overlooking the need for bone protection during steroid therapy 3

Remember that while steroids are effective for inducing remission, they are not effective for maintaining remission or healing mucosal lesions 3. The goal should be to use the most effective steroid with the lowest side effect profile for the shortest duration possible.